The state of emergency medical care in the United States is pretty terrible, and it has been getting worse.

A report released by the American College of Emergency Physicians gave the United States an overall grade of D+. That's down from a C- in 2009. The researchers behind the report determine the grade by looking at five categories:

Ease of access to emergency care

The quality and safety of the emergency room

Medical liability and insurance availability

Overall public health

Disaster preparedness

Here's how the United States ranked in each of the categories in 2009 compared to 2014:

The report also gives each state a grade. No state earned an A, and the highest grade for 2014 is B-. Wyoming is a disaster with the only failing grade in the country.

Naming names, here's the top ten worst and best states.

So why is the country's grade so abysmal? Here are some of the reasons from the report.

1. Widespread practice of "defensive medicine." Defensive medicine happens when doctors are extra cautious because of the potential liability and backlash of uninsured or underinsured patients — frequenters of emergency rooms. Emergency room doctors are also more likely to be sued for malpractice because of their fast-paced environment and the seriousness of the medical problems that patients come in with — treatment for more serious health problems is more likely to go wrong.

2. Not enough prescription drug monitoring. In 2011 there were 1.5 million emergency room visits due to prescription drug misuse. The report argues that emergency care providers need better access to patients' prescription drug histories, and prescription drugs (especially those that are typically misused) should be better regulated.

3. There aren't enough doctors trained to be emergency physicians. Based on the 2010 numbers, only about 4% of all practicing physicians are emergency physicians. This small number of physicians handles 28% of all acute care cases, 11% of all outpatient care cases, and two-thirds of uninsured patients.

4. There's not enough room for everyone. The CDC reported that the number of emergency departments has declined 11% from 1995 to 2010, while the number of people using emergency departments has been growing. Lack of funding and increasing demand means fewer doctors for more patients and longer waits.

Obamacare may not help

The report argues that the problem only going to get worse if no real changes are made. Emergency rooms are now giving the kind of care that used to be provided in physicians' offices, and the researchers think the Affordable Care Act will only worsen the trend.

"As more Americans become insured under the Affordable Care Act, many for the first time, emergency departments are likely to play a more pivotal role and to become more stressed," they state in the report. A recent study indicated that people with health insurance visit the ER more often, not less.

The researchers also suggest that the aging Baby Boom generation will end up in the ER more and more as they get sicker and older.

The researchers say that emergency medical care in the United States needs reformed liability laws, the development of more specialized emergency care services, more federal and state funding, and more emergency medical care education programs.

However, Forbes reported that the Affordable Care Act could expand insurance coverage to about half of the 60 million uninsured Americans. This increased coverage could take some of the financial burden off emergency care facilities, which are often uncompensated when uninsured patients are treated there. More insured patients would mean more money for emergency departments, which could be used to improve the state of emergency care.